health and rights to prevent HIV in adolescent girls and young women in eastern and southern Africa
Evidence brief
health and rights to prevent HIV in adolescent girls and young women in eastern and southern Africa
Evidence brief
Editing and layout: Green Ink, United Kingdom (greenink.co.uk)
Contents
Acknowledgements ii
Acronyms and abbreviations ii
Background 1
Regional consultation for eastern and southern Africa: overview 2 Steps to develop a comprehensive approach to HIV prevention for AGYW in the context of SRHR 3
1. Build on current commitments and national priorities 3
2. Ensure a comprehensive approach 5
3. Review evidence-based interventions for AGYW 7
4. Operationalize and evaluate multisectoral approaches: country strategies 9
5. Identify funding opportunities 13
Looking ahead 15
References 16
Additional recent key references 18
Annexes 19
Annex 1: Selected strategies, plans, frameworks, partnerships and funding mechanisms related to reducing HIV and advancing sexual and reproductive health and rights (SRHR) for adolescent girls and young women (AGYW): for 12 selected countries in eastern
and southern Africa (ESA) 19
Annex 2: National-level data on sexual and reproductive health and rights (SRHR) and HIV in adolescent girls and young women (AGYW): for 12 selected countries in eastern and
southern Africa (ESA) 20
Acknowledgements
This regional consultation was supported by the WHO Department of Reproductive Health and Research (RHR) and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the United States Agency for International Development (USAID) Microbicide Product Introduction Initiative (MPii). The consultation received technical input from colleagues at the WHO and UNAIDS headquarters in Geneva, Switzerland, the WHO Regional Office for Africa in Brazzaville, Congo, the WHO Intercountry Support Team (IST) in Harare, Zimbabwe, and the WHO Country Office in Namibia, as well as from the USAID headquarters in Washington, DC, and the USAID Country Office in Namibia.
Acronyms and abbreviations
AGYW adolescent girls and young women CCM Country Coordinating Mechanism CSE comprehensive sexuality education
DREAMS helping girls develop into determined, resilient, empowered, AIDS-free, mentored and safe women
ESA eastern and southern Africa
FP family planning
GBV gender-based violence
GFF Global Financing Facility
Global Fund the Global Fund to Fight AIDS, Tuberculosis and Malaria
HPV human papillomavirus
M&E monitoring and evaluation
MHSS Ministry of Health and Social Services of Namibia MPii Microbicide Product Introduction Initiative
PEPFAR The United States President’s Emergency Plan for AIDS Relief PrEP pre-exposure prophylaxis
RTI reproductive tract infection SRH sexual and reproductive health
SRHR sexual and reproductive health and rights STI sexually transmitted infection
UN United Nations
UNAIDS Joint United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNFPA United Nations Population Fund
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development WHO World Health Organization
Background
The AIDS epidemic continues to disproportionately affect sub-Saharan Africa, especially eastern and southern Africa (ESA). The ESA region has only 6.2% of the world’s population, but is home to half of the world’s people living with HIV (1). In 2015, the region accounted for 46% of the world’s new HIV infections and 42% of global AIDS-related deaths (2). An estimated 90% of new HIV infections among adults and young people in the ESA region occurs through sexual transmission (3).
Over the last several years, countries in the ESA region have made significant and commendable progress in preventing mother-to-child transmission (PMTCT) of HIV and in scaling up HIV treatment efforts. However, despite these gains, there have been no significant reductions in new HIV infections and the region continues to be the hardest hit by the epidemic, highlighting the need to place stronger emphasis on HIV prevention.
The risk of HIV infection among adolescent girls and young women (AGYW)1 in the ESA region is of particular concern. The 2016 UNAIDS World AIDS Day report, Get on the Fast-Track – The life-cycle approach to HIV, stated that efforts to reduce new HIV infections among young people and adults have stalled, threatening to undermine progress towards ending AIDS as a global public health threat by 2030 (4). Between 2010 and 2015, the number of new HIV infections among young people and adults has not decreased rapidly enough, and remains unacceptably high among young girls and women (10–24 years old). In 2015, there were approximately 4500 new HIV infections weekly among AGYW in the ESA region, double the rate for adolescent boys and young men (5). AGYW continue to experience elevated HIV risk and vulnerability. AIDS-related illnesses are also the leading cause of death among women and girls of reproductive age (6). The cycle of heterosexual HIV transmission from older men to younger women and girls, and the particular biological and socioeconomic vulnerabilities of AGYW are some of the reasons for the disproportionately high burden of HIV infections among AGYW (7). This underscores the critical need for HIV prevention interventions and approaches that can effectively reach this population while helping them to realize their aspirations.
A growing number of organizations and financing mechanisms as well as national governments are working to respond to this challenge through policy frameworks, programmatic interventions, and funding initiatives specifically targeted to AGYW. Many of these efforts emphasize the critical importance of a comprehensive approach that goes beyond an HIV-prevention agenda, and the need for partnerships to successfully combine programme elements across domains. These could include other health areas such as sexual and reproductive health and rights (SRHR), as well as education and financial security. Governments and donors are looking for effective approaches and ways to scale them up nationally so they can have a real, sustainable and long-term impact on the lives of AGYW.
Some evidence exists regarding the effectiveness of specific interventions to help AGYW manage their HIV risk.
Core areas of action that target both risk and vulnerability reduction include information to develop knowledge;
opportunities and support to develop life skills and independence; appropriate and accessible health services for young people; and the creation of a safe and supportive environment and promotion of gender equality. More specifically, there are several evidence-based interventions that support a continuum of care which could be adapted or built upon to meet the multiple health needs of AGYW (8). These interventions include school-based comprehensive sexuality education (CSE), community-based CSE to take into account the large numbers of adolescent girls who are not in school, and provision of quality sexual and reproductive health (SRH) services, with efforts to create safe and supportive youth-friendly environments at schools, health-care facilities and other venues in the community. The role of parents, guardians and grandparents in providing safe and nurturing environments at home also remains essential to the well-being of AGYW (8).
1. Adolescent girls and young women (AGYW) are defined in this document as female persons 15–24 years of age, inclusive. It is acknowledged that countries may have other definitions under their respective national laws.
Packages of integrated interventions for AGYW can include efforts to address early and/or unintended pregnancy, unsafe abortion, sexually transmitted infections (STIs), violence against women and girls, and efforts to combat harmful practices such as child marriage and female genital mutilation (FGM). Implementing and scaling up integrated packages of interventions that include HIV prevention for AGYW, however, remains a particularly complex and critical challenge.
Regional consultation for eastern and southern Africa: overview
The World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS), in collaboration with the United States (U.S.) President’s Emergency Plan for AIDS Relief (PEPFAR) and the United States Agency for International Development (USAID), co-convened a regional consultation to elaborate approaches and strategies for reaching AGYW in the ESA region with HIV prevention in the context of sexual and reproductive health and rights (SRHR), and in light of current policy and funding opportunities. The meeting was hosted by the Ministry of Health and Social Services (MHSS) of Namibia, which has taken a leadership role in addressing the HIV epidemic among AGYW as the “Stay Free” ambassador (with a focus on stopping the cycle of new infections among AGYW) for the Start Free, Stay Free, AIDS Free framework (see Box 1). It was held in Windhoek, Namibia, on 1–3 February 2017.
The consultation brought together more than 190 participants from the Namibia MHSS, the Ministry of Sport, Youth and National Service, the Ministry of Education, Arts and Culture, representatives of national AIDS programmes from 12 selected ESA region countries,2 members of civil society including youth representatives, and researchers.
Participants were also drawn from the regional and international staff of the DREAMS Partnership and the Microbicide Product Introduction Initiative (MPii) (see Box 1), the Bill & Melinda Gates Foundation, the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund), and from global, regional and country offices of United Nations (UN) agencies, including WHO, UNAIDS, the United Nations Population Fund (UNFPA), the United Nations Children’s Fund (UNICEF) and the United Nations Educational, Scientific and Cultural Organization (UNESCO).
Through plenary presentations involving all participants and separate small-group discussion sessions among country teams, participants worked together to deepen their understanding of ongoing efforts to link HIV prevention and SRHR programmes for AGYW.
Participants at the consultation also discussed how to tailor a package of evidence-based, integrated programme interventions to particular sites and country contexts where some of these efforts may not yet have started.
Discussions also considered how to operationalize an integrated approach to reaching AGYW that can be incorporated into country proposals for HIV funding, including current opportunities from PEPFAR (9) and the Global Fund (10).
All participants benefited greatly from dynamic presentations made by the Minister of Health and Social Services, Hon. Dr Bernard Haufiku, and Her Excellency the First Lady of the Republic of Namibia, Madame Monica Geingos, who each offered eloquent, frank and personal speeches about the critical importance of reaching young people, and of working with and listening to them. Madame Geingos described the partnership among government agencies that has helped AGYW in Namibia, and the importance of meeting young people where they are – in familiar and comfortable settings – and through language and media they use. Dr Haufiku stressed the overarching
2. Botswana, Kenya, Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Uganda, United Republic of Tanzania, Zambia, Zimbabwe. These 12 countries were selected for participation in the consultation because they had six or more of the strategies, frameworks, partnerships and funding mechanisms relevant for integrated SRHR–HIV interventions for AGYW listed in the table in Annex 1.
benefits to AGYW of staying in school, and described his collaboration with the Ministry of Education, Arts and Culture to strengthen school access and retention for girls in Namibia. He stated his commitment to strengthening linkages with SRHR, and reminded participants that while it is important to accommodate the concerns of conservative voices as far as possible, those elements must not be allowed to block services for AGYW. The U.S. Ambassador to Namibia, His Excellency Mr Thomas F. Daughton, underscored the importance of placing AGYW at the centre of the AIDS response. He commended Namibia for its leadership in addressing HIV among AGYW, expressed support for the linkages between SRHR and HIV programming, and pledged ongoing support, including PEPFAR’s commitment to directing additional funds to programmes working with AGYW in Namibia (11).
Steps to develop a comprehensive approach to HIV prevention for AGYW in the context of SRHR
This technical brief summarizes the key concepts and policy-level efforts related to reaching AGYW with HIV prevention through integrated SRHR–HIV approaches. It builds on the discussions and outcomes at the regional consultation, structured according to the following five steps:3
1. Build on current commitments and national priorities 2. Ensure a comprehensive approach
3. Review evidence-based interventions for AGYW
4. Operationalize and evaluate multisectoral approaches: country strategies 5. Identify funding opportunities.
1. Build on current commitments and national priorities
This step involves the following tasks:
n Map the context, including identifying relevant global, regional and national initiatives and frameworks, as well as strategic links with national priorities.
n Map stakeholders and partnerships that could help advance the national targets and goals.
n Define the steps that will be required to gain stakeholder buy-in, and to form and strengthen partnerships and coordination mechanisms.
HIV programmes have seen some impressive successes; for example, in making HIV testing and antiretroviral therapy (ART) available, preventing vertical transmission, and rolling out voluntary medical male circumcision.
Many of these successes have been delivered through siloed programme interventions. However, such approaches have not been effective in reaching AGYW with HIV prevention.
Strengthening comprehensive and holistic approaches to health presents three key challenges: (i) to break down silos between programmes and institutions within the health sector, (ii) to break down silos between the health and other sectors, such as education, and (iii) to ensure simultaneous, complementary actions at national, provincial/
district and local levels.
Sustainable Development Goal 3 (SDG 3: Ensure healthy lives and promote well-being for all at all ages)4 and the United Nations (UN) Secretary-General’s Global Strategy for Women’s, Children’s and Adolescents’ Health (12) mark
3. Based on ongoing work on integrating elimination of mother-to-child transmission (eMTCT) and reproductive, maternal, newborn and child health (RMNCH) by the UNFPA, WHO and partners of the Inter-Agency Working Group on SRH and HIV Linkages.
4. For further information, see: http://www.un.org/sustainabledevelopment/health/
an opportunity and a mandate for the global development agenda. Numerous other health-related frameworks, strategies and plans have emerged at global, regional and national levels in recent years. They underscore the growing and relatively recent commitment to addressing HIV among AGYW and provide a clear mandate for HIV programming (see Box 1). Many of the policy frameworks aimed at addressing HIV prevention note the importance of linking with SRHR in order to reach AGYW with comprehensive services.
Box 1: Strategies, plans, frameworks, partnerships and funding mechanisms on reducing HIV and advancing SRHR for AGYW
n SRH & HIV Linkages Resource Pack: Compiled by the Inter-Agency Working Group on SRH & HIV Linkages, the Resource Pack includes national assessments, presented as HIV and SRHR linkages infographic snapshots;
available at: http://srhhivlinkages.org/srh-hiv-linkages/#infographic-snapshots
n Eastern and southern Africa (ESA) ministerial commitment: At a high-level ministerial meeting at the UNAIDS headquarters in Geneva in May 2016, ministers of health from ESA countries made commitments on policy and programmatic action and increased investment to revitalize HIV prevention, in particular for primary prevention at the local level for adolescents. Further information: http://www.unaids.org/en/resources/
presscentre/featurestories/2016/may/20160525_ESA_ministers
n UNAIDS Fast-Track: UNAIDS 2016–2021 strategy: on the fast-track to end AIDS (13) was published in 2015 and the Political declaration on HIV and AIDS: on the fast-track to accelerate the fight against HIV and end the AIDS epidemic by 2030 (14) was subsequently issued at the 2016 High-Level Meeting on Ending AIDS (UN General Assembly, June 2016). UNAIDS guidance aims to fast-track HIV prevention among AGYW while also engaging men and boys (6). It puts the focus on subnational settings with the highest rates of new HIV infections, and on ensuring that programmes respond to specific risk factors. It outlines specific decision criteria for prioritizing programme components as well as a management framework and a set of core capacities. Based on available evidence and programming experience, countries and districts can choose from a menu of several options (6).
n ALL IN to #EndAdolescentAIDS: A joint UNICEF and UNAIDS platform to accelerate reduction in AIDS-related deaths and new HIV infections among adolescents (aged 10–19) with zero discrimination (15). Further information: http://allintoendadolescentaids.org/
n The DREAMS Partnership – helping girls develop into determined, resilient, empowered, AIDS-free, mentored and safe women: DREAMS was launched on World AIDS Day in 2014 to reduce HIV infections among AGYW in 10 sub-Saharan African countries (16). The DREAMS Partnership includes a number of interventions in its core package to empower AGYW, reduce risk of sex partners, strengthen families and mobilize communities for change. These interventions go beyond the health sector, addressing the structural drivers that directly and indirectly increase girls’ HIV risk, including poverty, gender inequality, sexual violence and lack of education. The country-level programmes include different elements depending on national priorities, evidence and feasibility, and DREAMS initiatives are now being mainstreamed into PEPFAR country operational plans. Rigorous monitoring and evaluation (M&E) will provide invaluable information for assessing existing programmes as well as informing programmes for AGYW in other settings in DREAMS countries and in other countries. Further information: http://www.dreamspartnership.org/
n USAID Microbicide Product Introduction Initiative (MPii): MPii comprises five interconnected projects working in Kenya, South Africa and Zimbabwe, and could be a resource for other country programmes (2015–2020). Further information: http://www.prepwatch.org/policies-and-programs/usaid-supported- initiatives/. The five MPii projects are:
• EMOTION – Enhancing Microbicide Uptake in High-risk End Users
• CHARISMA – Community Health Clinical Model for Agency in Relationships and Safer Microbicide Adherence
• GEMS – Global Evaluation of Microbicide Sensitivity
• POWER – Prevention Options for Women Evaluation Research
• OPTIONS – Optimizing Prevention Technology Introduction on Schedule
n UNFPA/WHO/UNAIDS SRHR and HIV Linkages in East and Southern Africa: This project seeks to make a difference in health service delivery by linking SRHR and HIV at the policy and system levels. Further information: http://esaro.unfpa.org/topics/srhr-and-hiv-linkages-project
n The Global Fund to Fight AIDS, Tuberculosis and Malaria: The Global Fund provides Catalytic Matching Funds for human rights and/or AGYW. Related Global Fund strategies and documents: The Global Fund strategy 2017–2022: investing to end epidemics (17), Strategic investments for adolescents in HIV, tuberculosis and malaria programs (10), and Technical brief: adolescent girls and young women in high-HIV burden settings (18).
n Global Financing Facility (GFF): The GFF was launched in July 2015 to support the goals of the Global Strategy on Women’s, Children’s and Adolescents’ Health under the purview of the UN Secretary-General.
The GFF mechanism supports countries to develop the investment case for priority interventions. Further information: https://www.globalfinancingfacility.org
n The UN Secretary-General’s Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030): survive, thrive, transform (12). Further information: http://www.everywomaneverychild.org/
global-strategy/
n The Global Framework for Accelerated Action for the Health of Adolescents: AA-HA! (2016–2030) provides guidance on how to plan, implement and monitor an effective response to the health needs of adolescents in line with the Global Strategy for Women’s, Children’s and Adolescents’ Health (19).
n Health for the world’s adolescents: a second chance in the second decade (20).
n Start Free, Stay Free, AIDS Free is a super-fast-track framework to accelerate the end of the AIDS epidemic among children, adolescents and young women by 2020; it was launched by UNAIDS, PEPFAR and the Global Fund in December 2016. Further information: https://free.unaids.org/
n The WHO Global Health Sector Strategies for HIV, viral hepatitis and sexually transmitted infections (2016–2021) (21–23). Further information: http://www.who.int/hiv/strategy2016-2021/en/
n The WHO global plan of action to strengthen the role of the health system within a national
multisectoral response to address interpersonal violence, in particular against women and girls and against children (24).
However, these initiatives do not in themselves benefit AGYW without implementation, and while there are some good examples to build on, implementation has been weak overall. Participants at the regional consultation noted that no more frameworks are needed; now is the time for implementation and action.
2. Ensure a comprehensive approach
This step involves identifying key concepts and principles of an integrated SRHR–HIV approach to interventions for AGYW and including these in health policy, systems and service delivery.
The necessity of working across sectors was reinforced as a central theme throughout the presentations and discussions, and participants reviewed different approaches to developing comprehensive, integrated programmes.
The contours of specific cross-sectoral programmes must be responsive to each country and local setting. The urgency of working with AGYW calls for balancing evidence with experimentation in the face of uncertainty, and to achieve impact there must be willingness to be creative and bold within the constraints of existing resources.
A comprehensive approach to SRHR, as defined in WHO’s 2004 reproductive health strategy includes: improving antenatal, perinatal, postpartum and newborn care; providing high-quality services for family planning (FP), including infertility services; eliminating unsafe abortion; combating STIs (including HIV), reproductive tract infections (RTIs), cervical cancer and other gynaecological morbidities; and promoting sexual health (25). It also includes cross-cutting elements: human rights, gender equality, preventing vertical transmission of HIV, and
OUTPUT OUTCOME IMPACT More enabling environment for
a linked SRH and HIV response
More integrated delivery of HIV and SRH services
Reduced HIV related stigma and discrimination*
Increased access to and utilisation of quality integrated HIV and SRH services
Reduced gender based violence*
Improved programme efficiency and value for money
Improved health, human
rights and quality of life Stronger health systems
which support SRH and HIV integration
preventing violence against women and girls. Given that good quality preventive and curative health services are needed, but in themselves cannot reduce HIV acquisition and other SRH problems among AGYW, a stronger focus on interventions to address social determinants is also required.
SRHR and HIV linkages and integration defined
Linkages: The policy, programmatic, service and advocacy synergies between SRH and HIV.
Integration: The different kinds of SRH and HIV services and/or operational programmes that can be joined together to ensure collective outcomes. This would include referrals from one service to another. It is based on the need to offer comprehensive services.
Source: WHO, UNFPA, IPPF, UNAIDS, 2005 (26).
SRHR–HIV linkages: Catalysed by the Glion Call to Action in 2004 (27), the field of SRHR and HIV linkages has developed several models of integrated and linked approaches at the levels of law and policy, health systems and service delivery. This concept draws on a theory of change that posits that a more enabling environment can lead to strong health systems that support SRHR–HIV integration and lead to more integrated delivery of SRHR and HIV services (see Fig. 1) (28). Both individually and together, approaches at these three levels (law and policy; health system; service delivery) lead to a number of outcome-level benefits, including: reduced HIV-related stigma and discrimination; increased access to and utilization of good-quality, integrated HIV and SRHR services; reduced gender-based violence (GBV); and improved programme efficiency and value for money. Therefore, supporting interventions that link SRHR and HIV has the potential to positively impact health, human rights and quality of life.
Over more than a decade, country programmes have implemented and documented integrated SRHR–HIV efforts that have combined different components. These methods have provided examples of how an integrated, multisectoral approach could support improvements in joint SRHR–HIV health outcomes. Further information on SRH–HIV linkages, including examples of such efforts, is available at: http://www.who.int/reproductivehealth/
topics/linkages/en/
Figure 1: Theory of change for SRH and HIV linkages
Source: IPPF, UNFPA, WHO, 2014 (28).
* It is recognized that reducing stigma, discrimination and GBV are also impact-level measures and the outcome measures influence each other.
3. Review evidence-based interventions for AGYW
This third step requires assessing existing evidence on the effectiveness of biomedical and structural interventions for reaching AGYW, as well as the effectiveness of integration of SRHR and HIV services.
3.1 Multisectoral programming
Examples of several national policies and programmes were presented and discussed at two global consultations convened by WHO in 2016 on using lessons from SRHR and STI programming to catalyse HIV prevention for AGYW.5 Initiatives that enable AGYW to have control and choice over their SRHR have the potential to break the cycle of gender relationships that have an imbalance of power, reduce pervasive GBV and intimate partner violence (IPV), and may also reduce HIV acquisition.
Promising, successful and potentially sustainable projects or interventions include those that:
n develop context-specific initiatives to enable girls to stay in school (which could also delay early marriage and prevent unintended pregnancy), including building infrastructure (e.g. schools), setting up cash transfers, and engaging and training more teachers;
n nurture economic independence through academic and vocational training;
n provide well designed, age-appropriate comprehensive sexuality education (CSE) programmes in schools and at other venues that reach out-of-school youth;
n improve access to HIV testing and comprehensive SRH services, including condom distribution, human papillomavirus (HPV) vaccination, screening and treatment for STIs and RTIs, quality FP services, and other biomedical interventions such as oral PrEP;6
n meaningfully engage young women throughout the development, implementation and evaluation of policies and programmes that affect them, to improve programme quality and policy relevance;
n engage boys and young men around risk reduction issues, including healthy sexuality and respectful relationships with girls and women, to change gender norms and behaviour;
n eliminate legal, economic and social barriers that result in unequal access to information, services and commodities; and
n enforce zero tolerance for all forms of coercion, violence and discrimination.
Measuring the impact of multisectoral interventions and investments by using single, narrow outcome indicators can undervalue their impact and cost–effectiveness. Integrated SRHR–HIV services provided in the same place at the same time can have multiple positive effects that will not be captured with narrow outcome measures such as the number of HIV infections averted. Multisectoral programmes can have even greater and more diverse positive outcomes. Ministries, funders and other actors need to ensure that the multiple and cross-cutting benefits of multisectoral programmes for young people are captured and that they factor into programme assessment, priority setting and resource allocation.
3.2 Rejecting the negative
Building on evidence also means not repeating what has not worked in reaching young people (29). A number of approaches have been tried and evaluated but have been found to be ineffective in improving SRHR-related outcomes, such as rates of HIV or unintended pregnancy. These approaches should therefore be abandoned so that scarce resources can be spent on effective interventions. Several approaches intended to reach adolescents have either failed to have an impact or made the work more difficult than it needs to be. Chief among these are:
5. Global consultation on lessons from sexual and reproductive health programming to catalyse HIV prevention for AGYW (April 2016) and Biomedical technologies to catalyze STI and HIV prevention for young women (May–June 2016). Available at: http://www.who.int/
reproductivehealth/topics/linkages/agyw-hiv-risk/en/
6. Oral PrEP is the oral use of antiretroviral medication (tenofovir plus emtricitabine) to prevent the acquisition of HIV infection by uninfected persons.
n vertical, siloed approaches, in which individual donors and/or implementers work alone or programmes target a single component of HIV or SRHR;
n health services for AGYW provided through freestanding youth centres;
n many peer counselling programmes;
n abstinence-only programmes;
n “one size fits all” approaches which assume that all adolescents face the same HIV risk;
n one-off training sessions for health workers on how to support the health needs of young people.
3.3 Youth-friendly services and meaningful inclusion of young people
Several elements of youth-friendly services were the focus of debate at the regional consultation.
n Possibly the most critical component of youth-friendly services are youth-friendly people who will provide health care and other services with real respect for their clients and without judgement.
n Some, especially young people, called for more youth centres that could deliver SRHR and HIV services to young people along with other programmes. Evidence has shown that, overall, these centres tend to attract young men, and are generally not accessible or welcoming to AGYW (29). It may be relevant to look at positive models, or to distil and make available lessons on youth centres and other models that might better appeal to and benefit AGYW.
n Promoting condom use for HIV prevention is a critical part of the AIDS response and can also prevent unintended pregnancy. While both male and female condoms have limitations for AGYW, they remain a viable and cost–effective solution that is often insufficiently promoted. Programmes need to ensure that condoms remain a central component of a comprehensive HIV-prevention package even as new technologies are developed and begin to be delivered. Efforts to promote condom use must include resources for creative marketing and programming as well as an effective supply chain for the commodities.
n Comprehensive sexuality education (CSE) needs to be implemented in and outside of schools and it should facilitate decision-making and build on AGYW’s aspirations and their interest in taking control of their lives.
Young people should be meaningfully included in designing programmes and services. Their insights and creativity can result in the development of truly youth-friendly services and programmes. Young people can provide
innovative ideas, such as making wifi available in waiting rooms at clinics so that waiting time is not seen as wasted.
Of course, effective programming is not all about bringing in new perspectives and creativity, but must be grounded in evidence. Key learning and best practices related to programmes for AGYW need to be distilled and made accessible so that this information is both useful and used. One important audience for this information and capacity-building is the young people who are increasingly being invited to present at conferences and advise on programmes, so that their personal lived experiences can be melded with evidence from programme experience and research evidence.
Clearly there is not one formula for comprehensive services for AGYW that can be implemented and applied across multiple settings, and every programme cannot meet every need. Programmes instead should consider what steps can be taken to better meet AGYW’s needs and aspirations. Rather than attempting to do everything at once, incremental steps can be made to strengthen SRHR–HIV linkages, making sure that every opportunity is taken to engage AGYW with the health system, to build trust and to create space for AGYW who have come in for one service (e.g. an HPV vaccination) to return at a later date for other services (e.g. counselling on HIV risk, alcohol abuse and safer sex).
3.4 Key principles for providing a comprehensive approach to SRHR–HIV linkages
n Uphold human rights and gender equality: The rights of AGYW – particularly the most vulnerable and at-risk among them – need to be upheld. This requires gender-sensitive policies to establish gender equality and eliminate violence.
n Ensure a coordinated and coherent response: Attention to SRH priorities should be promoted within a coordinated and coherent response to HIV that builds upon the principles of one national HIV framework, one broad-based multisectoral HIV coordinating body, and one agreed, country-level M&E system (the “Three Ones”
key principles) (30).
n Reduce stigma and discrimination: More vigorous legal and policy measures are urgently required to protect AGYW.
n Recognize the centrality of sexuality: Sexuality is an essential element in human life and in individual, family and community well-being. Yet speaking of sex and sexuality to AGYW remains among the more challenging issues facing families, schools, communities and health services.
n Place AGYW at the centre of the response: This requires that AGYW are empowered – through education and support – to make and enact decisions in all aspects of their lives, including in relation to sexuality and reproduction. Initiatives must be organized around the health needs and priorities of AGYW themselves rather than HIV prevention and control (Fig. 2).
• Keeping girls in school
• Social and behavioural change communication
• Prevention of violence
• Comprehensive sexuality education
• Promoting self-efficacy and empowerment
• HPV vaccination
• Condoms
• Contraception
• PrEP
AGYW
Biomedical prevention Societal
interventions
Structural interventions Figure 2: HIV prevention for AGYW in the context of SRHR
4. Operationalize and evaluate multisectoral approaches: country strategies
This fourth step involves three component activities:
n Design and implement different types of integrated or linked service-delivery programmes depending on the national context and local needs.
n Monitor and evaluate these programmes, including adapting them as needed.
n Support efforts to take successful programmes to scale.
4.1 Ideas for programmes offering packages of interventions for AGYW
Some important ideas were generated at the regional consultation, which can provide a basis for continued work at the country level.
Countries are seeking information on how best to combine programme elements to meet the needs of AGYW and how best to scale up successful programmes. Decisions on priorities should be made based on country-level data and local contexts. Several country reviews are available, such as those by PEPFAR (31). A number of programme examples were presented at the meeting, including the DREAMS Partnership, the UNAIDS Fast-Track initiative and USAID’s MPii (see Box 1) and countries can refer to these as they work to develop and assess packages of interventions for AGYW.
Countries have quite diverse experiences, but the recent urgency to focus on AGYW has at times led to disparate and sometimes disconnected efforts. Work in this area is not sufficiently coordinated and lessons are not adequately realized or transferred between programmes to benefit AGYW.
Virtually all countries called for mapping of interventions and implementing partners to help them understand what programmes are being planned and implemented, what is working and what can be learnt from these
programmes, gaps to be filled and successes that can be built upon. This is especially urgent at the country level, but would also be useful at local, global and regional levels.
4.2 Country-level programmes
Namibia’s Youth Task Force could potentially serve as a model for coordination (see Box 2). Other country-level initiatives are described in alphabetical order by country in the remainder of this subsection.
In Botswana, several parent–child dialogue platforms and multimedia educational programmes for public education on sexuality and HIV prevention have been successful in reaching AGYW with prevention messages and interventions.
These policies and programmes are also aimed at structural interventions, such as reducing violence against women and girls, and biomedical interventions, such as introduction of HPV vaccination in schools.
Kenya is rolling out several programmes that involve introducing PrEP to HIV-serodiscordant couples, young women attending FP clinics, and key populations,7 including female sex workers. This is being coordinated and led by the National AIDS and STIs Control Programme (NASCOP) in collaboration with several partners. Kenya also has an integrated SRH–HIV strategy and there is an opportunity to place the introduction of PrEP to AGYW in the context of comprehensive SRHR.
In Lesotho, the strong political commitment and ownership means that 75% of antiretroviral medicines are procured by the government. The National Health Policy 2011–2016 currently under review offers possibilities to include measures to reach AGYW with comprehensive SRH and HIV interventions.
South Africa’s She Conquers campaign is being implemented in the 27 districts with the highest HIV burden. The campaign has five objectives that exemplify an integrated approach: reducing new HIV infections among AGYW;
reducing the incidence of teenage pregnancy; increasing retention of girls in school until completion of secondary school/grade 12; reducing sexual abuse and GBV; and increasing economic empowerment of girls and young women.
The structure, goals and target populations of the campaign are informed by evidence that demonstrates the undue burden placed on AGYW, the negative long-term effects that result from this, and the HIV transmission pathway. The
7. “Key populations are defined groups who, due to specific higher-risk behaviours, are at increased risk of HIV irrespective of the epidemic type or local context. Also, they often have legal and social issues related to their behaviours that increase their vulnerability to HIV” (32).
This may include, among others: men who have sex with men, people who inject drugs, people in prisons and other closed settings, sex workers, and transgender people.
campaign has catalysed stakeholders around common goals and a core package of interventions that can have beneficial impacts for society, even beyond AGYW. However, implementing the campaign activities down to the sub-district level is time-consuming and mobilizing limited resources has also been problematic. This example of a country-owned and -led initiative resonated with some of the country participants at the regional consultation.
In Swaziland, several steps have been taken at the policy, systems and service-delivery levels to support an integrated approach with the potential to reach AGYW with more comprehensive services. This approach includes:
integration of HIV interventions within the service-delivery platform for maternal, newborn and child health (MNCH);
reducing the age of sexual consent to 12 years of age; and training of health-care providers in adolescent sexual and reproductive health (ASRH), FP and GBV, and supporting adolescent-friendly health services.
In Uganda, the Adolescent Health Technical Working Group (under the leadership of the Ministry of Health/National AIDS Control and the Reproductive Health Unit) has shown success in reaching AGYW with services to reduce violence, HIV and unintended pregnancy. The Empowered Livelihoods Adolescents (ELA) programme model, for example, integrates livelihood skills training, SRHR and HIV sensitization, and service delivery that is responsive to cultural and traditional practices. This has allowed for better uptake of both SRH and HIV services by AGYW.
In the United Republic of Tanzania, the 2016 National Multisectoral Strategic Framework for HIV Prevention reflects the need to reach AGYW in all key areas. Critical to the development of this framework were ministerial leadership and meaningful engagement of civil society. The adolescents and young adults stakeholders (AYAS) group, for instance, has been important in bringing people together to discuss the best ways to advance the health
Box 2: Namibia’s Youth Task Force
Both the First Lady and the Minister of Health and Social Services of Namibia underscored how important this mechanism has been in facilitating Namibia’s work for AGYW. The main government agencies responsible for working with youth come together in monthly meetings, including the Ministry of Health and Social Services (MHSS), the Ministry of Education, Arts and Culture, the Ministry of Gender and Child Welfare, and the Ministry of Sport, Youth and National Service.
Her Excellency the First Lady of the Republic of Namibia, Madame Monica Geingos, noted several factors that are key to this process:
n Identifying clear goals for the short, medium and long term to help break down the large and complex areas of work.
n Specifying clear leadership responsibilities such that one agency – in this case the MHSS – is charged with driving the process forward.
n Using technology such as WhatsApp for communication among the Task Force members and with adolescents seeking information.
n Ensuring that the country’s leaders and ministers establish a clear commitment and mandate that working together is critical and is expected.
n Being creative and open, and meeting young people at locations where they usually gather and feel comfortable – Madame Geingos described convening a group of young people at a popular nightclub, and trusting them to identify their own priorities and approaches to the discussion, resulting in an open airing of topics, some of which were complex and sensitive, including unwanted sex, the implications of age of consent laws, and GBV.
The First Lady also stressed that collaboration and cross-sectoral programmes can be initiated and maintained even without additional funding. Madame Geingos noted that circumstances for such joint work will never be perfect – but it must be done anyway. The First Lady uses her social capital to drive forward work with young people, including collaborating with her predecessor when she can to help forge relationships and maintain momentum.
and rights of AGYW. The multisectoral youth forum brought together a wide range of national stakeholders concerned and involved with ASRH, adolescent-friendly SRH services, parenting, gender, economic empowerment and protection for adolescents, and social media, as well as M&E.
In Zambia, the initiative to provide clinical outreach services to adolescents in the community reaches out-of- school girls and women, rather than focusing on AGYW in schools, like many other programmes. The initiative offers one-stop, youth-friendly centres where SRH, HIV and GBV services are offered by trained providers in safe spaces specifically for AGYW. It is being considered for scale-up.
In Zimbabwe, the Sista2Sista Club programme supports the peer-to-peer models that have been shown to be effective in reaching almost 10 000 AGYW with HIV prevention and other preventive health messages. It has also supported an increase in HIV testing and treatment, adherence to treatment for young people living with HIV, and many integrated SRH–HIV services.
As demonstrated by some of these country-level initiatives, success at the national level can be reached through country-owned programmes.
Programmes need to be adapted in different countries and settings based on national priorities and evidence as well as feasibility. Intervention packages should also be appropriate to each specific socioeconomic and cultural context, and accessible, affordable and acceptable to AGYW. At the same time, it is important not to revert to designing programmes that include elements that are merely convenient. In seeking to develop or expand programmes to be more comprehensive, countries need to balance the need for experimentation and expansion with the risk of overburdening and thereby potentially jeopardizing programmes that are working.
4.3 National-level data for use in programme planning
National-level data for AGYW are provided in the 2016 HIV and SRHR linkages infographic snapshots.8 Some of the data taken from these snapshots for the 12 ESA region countries included in the consultation are presented in Annex 2.9 The majority of the data in these snapshot documents are sourced from national Demographic and Health Surveys (DHS) and from UNAIDS; these were the data that were available up to 31 December 2015, although it is acknowledged that newer data for some of the data points may be available.10
In addition, the SRHR and HIV Linkages Index is a new web-based tool that has the potential to assess progress made towards achieving a fully linked SRHR–HIV response through creating a more enabling environment, building stronger health systems and providing more integrated services.11 The Index’s “heat map” is shown in Fig. 3: the countries with darker colours have a higher level of SRHR–HIV linkage. Additional information on each country is available by clicking on that country at the website.12
Sixty countries were chosen for inclusion in this Index, including those identified as priority countries for large global donors (e.g. PEPFAR and the Global Fund). Seventeen of the chosen countries are in the ESA region. This tool provides the first ever composite score on the extent to which SRHR and HIV responses are integrated and interlinked at the national level.
8. Available at: http://srhhivlinkages.org/srh-hiv-linkages/#infographic-snapshots
9. Please note that the Kenya infographic snapshot is at the sign-off stage and hence has not yet been published.
10. For the data sources and data years please see the relevant HIV and SRHR linkages infographic snapshot.
11. For further information, see: http://index.srhhivlinkages.org/
12. Available at: http://index.srhhivlinkages.org/map/
Figure 3: Heat map
Source: SRHR and HIV Linkages Index (http://www.who.int/reproductivehealth/topics/linkages/indicators/en/).
5. Identify funding opportunities
Finally, step 5 involves outlining the actions required to implement integrated SRHR–HIV interventions for AGYW and identifying what funding, technical assistance, guidance tools and supporting material may be required.
Important investment opportunities to reach AGYW now exist within several major global health funding bodies, including the Global Fund (10), the Global Financing Facility (GFF), and the DREAMS Partnership (see Box 1).
Indeed, one main impetus for convening the regional consultation was to provide national stakeholders with information on these immediate opportunities for funding and to create a space to discuss and identify possible proposals that include approaches to HIV prevention integrated with SRHR. The key elements of such proposals to the Global Fund are outlined in Box 3.
Box 3: Key elements of linked SRHR–HIV interventions for AGYW within HIV proposals to the Global Fund (33)
Linked SRHR–HIV interventions for AGYW within HIV proposals to the Global Fund should:
n Fit within overall national health policy, plans and strategies.
n Demonstrate that they improve/sustain HIV outcomes and also measure other benefits.
n Be defined in consultation with key stakeholders in SRHR/ASRH as formal participants in Country Coordinating Mechanisms (CCMs) and other policy-making bodies.
n Include a cost estimate and a timeframe for activities.
n Address gender inequalities, including violence, as underlying determinants of SRHR and HIV.
n Monitor and evaluate progress through measurable indicators of health, reduced violence, and other outcomes and benefits.
Presenting linked SRHR–HIV interventions within HIV proposals makes sense because the target behaviours and messages to address SRHR and HIV are often the same. Correct knowledge, access to commodities and services, and the confidence and skills to negotiate safer sex are shared objectives of sexuality education, FP and STI programmes, and HIV-prevention interventions. Young people do not separate their sexual behaviours and the potential consequences into neat boxes marked “HIV”, “pregnancy” and “other STIs” and programmes should be designed accordingly. Messages about the risk of exposure to HIV should address the realities of young people’s lives by taking a holistic approach that meets their SRH needs and respects their rights, irrespective of HIV status.
Programmatic responses are being implemented within the context of evolving processes within key funding agencies. Presentations and discussions at the consultation raised several critical points:
n The Global Fund’s overall strategy for 2017–2022 focuses on key and vulnerable populations with a target of reducing new HIV infections among AGYW to fewer than 100 000 by 2020. Its strategy and technical brief provide guidance on investing strategically in developing and implementing HIV-related programming for AGYW for the 2017–2020 funding cycle (10).
n Catalytic investments are made operational through several mechanisms for initiatives that are unable to be addressed through country allocations alone but deemed crucial to realizing Global Fund aims. Addressing HIV among AGYW is one of three programmatic areas eligible for matching funds within the HIV budget, and also falls within the Community, Rights and Gender Strategic Initiative. Funds for both are limited, and the Global Fund staff stressed that AGYW and HIV can also be incorporated into broader country HIV requests, for example through programmes aimed at building sustainable health systems, and promoting and protecting human rights and gender equality.
n Virtually all countries represented at the consultation noted that the existing CCMs will likely present a significant barrier to operationalizing the Global Fund’s stated commitment to AGYW. The CCM membership generally does not include experts in working with adolescents or SRHR. This means that the CCMs include neither the technical capacity to design programmes to meet the needs of AGYW nor the perspectives to champion such approaches. It is therefore difficult to see how bold and sustainable programming for AGYW will emerge, given the many competing priorities countries are contending with.
n The GFF (see Box 1) does not focus on HIV, but HIV-related interventions can be incorporated as a priority. It has an associated trust fund, and is examining a number of innovative financing mechanisms.
n Participants at the consultation called on donors to ensure that they involve in their mechanisms appropriate experts and stakeholders that match the scope of programmes designed to meet the needs of AGYW, from the programme design stage all the way through to evaluation. CCMs and other processes should incorporate new skills and perspectives, and outcome measures for programmes must be broadened to include indicators that address violence and unintended pregnancy, for example, as well as HIV.
n Donor recognition of the importance of AGYW in the AIDS response, and the particular approaches needed to reach AGYW, is an important milestone for global AIDS actors and presents opportunities – and challenges – for countries.
While the attention and commitment from global actors to AGYW is welcome, these opportunities may be short- lived. Countries can build on these funding and programming opportunities to put in place programmes that will be sustainable and benefit their young people over future generations.
Looking ahead
Most countries have policies for ASRH, and some have implemented successful programmes. Taking small, successful programmes to scale is a critical challenge and there are only a few success stories of scaling up programmes for AGYW for broader or national impact. The discussions at the regional consultation highlighted a range of resources, tools and guidance for programme design, implementation and monitoring that countries can adapt and use. Country teams at the meeting all endorsed an integrated approach, and called for better
communication, mapping and partnerships to maximize programme impact.
Several next steps were proposed:
n Identify existing coordinating mechanisms or develop new ones to ensure that the diverse actors charged with programme implementation for and with AGYW are working together to maximize programme efficiency and impact. Partnerships at the national level need a lead actor or institution that is accountable for the
implementation of policies and programmes for AGYW and for managing collaborative activities with other relevant sectors and partners. Experiences from the Namibia Youth Task Force could inform this process (see Box 2).
n Map programmes, policies, advocacy and other activities across key sectors related to AGYW to facilitate learning and collaboration and avoid duplication. This is especially important as programmes seek to break out of existing silos where they may be more familiar with the key actors and initiatives.
n Explore and develop a few case studies of specific programme experience or coordination processes and mechanisms to illustrate possible best practices and address outstanding questions. Examples would be identified in collaboration with countries. This includes, in particular, creating spaces for dialogue between different stakeholders at the national level to find innovative solutions.
n Advocate with donors and other key players to ensure that priority-setting processes and mechanisms include expertise in SRHR and AGYW, as well as diverse community voices, in sufficient numbers to influence their deliberations and decisions. Work with CCMs and PEPFAR colleagues to identify experts who can serve on drafting teams, and determine which funding mechanisms available for AGYW programmes best match different types of programming initiatives.
n Monitor, evaluate and document the scale-up of integrated HIV-prevention and SRHR interventions for AGYW in the context of different initiatives, including identifying optimal approaches to scaling up the delivery of successful interventions. This includes putting in place mechanisms to ensure that interventions can adapt to lessons learnt from implementation of policies and programmes.
n Work with the conveners and sponsors of key upcoming meetings to ensure that the messages, outcomes and priorities inform their planning and deliberations.
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Additional recent key references
World Health Organization:
n 16 Ideas for addressing violence against women in the context of the HIV epidemic (2016) http://apps.who.int/
iris/bitstream/10665/95156/1/9789241506533_eng.pdf
n Core competencies in adolescent health and development for primary care providers: including a tool to assess the adolescent health and development component in pre-service education of health-care providers (2015) http://apps.who.int/iris/bitstream/10665/148354/1/9789241508315_eng.pdf
n Financing health care for adolescents: a necessary part of universal health coverage (2015) http://www.who.int/
bulletin/volumes/93/1/14-139741/en/
n Global standards for quality health-care services for adolescents – a guide to implement a standards-driven approach to improve the quality of health-care services for adolescents, Volumes 1–4 (2015) http://apps.who.
int/iris/handle/10665/183935
n Adolescent HIV testing, counselling and care – online implementation tool (2014) http://apps.who.int/
adolescent/hiv-testing-treatment/
n HIV and adolescents: guidance for HIV testing and counselling and care for adolescents living with HIV:
recommendations for a public health approach and considerations for policy-makers and managers (2013) http://apps.who.int/iris/bitstream/10665/94334/1/9789241506168_eng.pdf
Joint United Nations Programme on HIV/AIDS (UNAIDS):
n Women and adolescent girls on the fast-track to ending the AIDS epidemic (2016) http://www.unaids.org/sites/
default/files/media_asset/2016WHA_Side%20event_brochure_NumPrint.pdf
n Children, adolescent girls and young women: preventing new HIV infections (2016) http://www.unaids.org/en/
resources/presscentre/featurestories/2016/june/20160610_panel5
n Women living with HIV speak out against violence: a collection of essays and reflections of women living with and affected by HIV (2014) http://www.unaids.org/sites/default/files/media_asset/womenlivingwithhivspeakout_
en.pdf
n The GAP report 2014: adolescent girls and young women (2014) http://www.unaids.org/sites/default/files/
media_asset/02_Adolescentgirlsandyoungwomen.pdf
n Gender-responsive HIV programming for women and girls: guidance note (2014) http://www.unaids.org/sites/
default/files/media_asset/genderresponsiveHIVprogramming_en.pdf United Nations Children’s Fund (UNICEF):
n Current status + progress: turning the tide against AIDS will require more concentrated focus on adolescents and young people (2016) https://data.unicef.org/topic/hivaids/adolescents-young-people/
n Guidance document: strengthening the adolescent component of national HIV programmes through country assessments: adolescent assessment and decision-makers’ (AADM) tool (2015) https://data.unicef.org/
wp-content/uploads/2016/04/Guidance-on-Country-Assessments-9_1_2015_252.pdf The United States President’s Emergency Plan for AIDS Relief (PEPFAR):
n PEPFAR priority areas: adolescent girls and young women: creating gender equality (2016) https://www.pepfar.
gov/documents/organization/264910.pdf
